Head-to-Toe Assessment Date:

Assessment conducted by Time:

LOC o Other:
 Alert Drowsy Lethargic
StuporousComa  Temp vs. trunk (warm / cool)
Orientation  Grip equal and strong
 Person  Capillary refill <3 sec
 Place  Vein filling rapid
 Time
 Situation
Vitals
 Temp R Lower Extremities
 BP Pulse Ox  Hair present
Head  Edema
 Hair  Foot strength
 PERLA mm  Homain's (+ / -) Claudication (+ / -)
 Nose  Temp vs. Trunk (warm / cool)
 Ears  Nails  Yellowed  Thickened  Ingrown
 Mouth
o Midline tongue
 Pedal pulse R(palp / doppler) L(palp / doppler)
o Moist ROM / Strength
 Upper R  Upper R
o Lesions  Upper L  Upper L
 Lower R  Lower R
o Dentition  Lower L  Lower L
 Sensation
Neck
 Carotid pulse  JVD + Trachea midline
Chest General Assessment
 Apical Pulse Muffled Arrhythmia  Weight/Height
 Breath Sounds - Anterior  BM
Posterior Lateral Pain Assessment
 Acute/Chronic  Intensity (0-10)
 Chest Symmetry  Location
 Skin Turgor (clavicle)  Duration
Abdomen  Characteristics
 Inspection  Precipitation
 Ausculation  Frequency
o LUQ (active / hyper / absent)  Non-verbals
o RUQ (active / hyper / absent)  Relief factors
o LLQ (active / hyper / absent)  Sleep
o RLQ (active / hyper / absent) Skin Assessment
 Palpation  Description:

Upper Extremities
 Radial pulses equal, +2
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